JS Free Clinic New Standardized Method of Documenting Reproductive Status of Adult Female patients

At its clinical services meeting June 6, 2012, the group adopted the following protocol for the standardization of documentation of reproductive status of adult female patients.

If you have questions about how to follow these instructions, please contact staff physician Katherine Cole at kjcolemd@gmail.com or medical director Winston Liaw at winstonrliaw@gmail.com. 

Based on the information obtained , providers will complete the progress note at every clinical visit as follows:

--Provider will note LMP (last menstrual period) which rooming assistant will have filled out on the vital sign sheet.

--Click on GYN in adult female patient progress note (if you do not see GYN history in the progress note, please contact Margaret Skelly, margaret@jsfreeclinic.org).

--Complete 2 lines in the progress note, which are visible in one screen:

1) Periods:  (examples of possible notations --regular, menopausal )

2) Birth Control: (examples of possible notations--none-patient desires to conceive, none--not at risk for pregnancy, Partner had vasectomy, Bilateral tubal ligation 2006).

This information will need to be confirmed at every visit, but if there are no changes in status, no changes will need to be made once you have clicked on GYN to import it into the progress note. 

Based on the information gathered and documented, providers will be able to decide whether any further steps are needed in regard to medication management of acute and chronic medical problems,  contraception counselling , or preconception counselling . This document does not address management of these issues.

Background to this decision:

Medical  providers need  to be aware of reproductive status prior to prescribing acute and chronic medications to women, and to be able to provide counselling regarding use of medications during  pregnancy or when patient is at risk for pregnancy. Providers should also offer preconception counselling and contraceptive counselling and services when indicated.

At JSFC over the last 2 years we have identified this problem, and at  prior clinical services meetings adopted several changes including :

 1) Implemented a health history form that is completed at enrollment; the form specifically asks female patients about reproductive status and contraceptive use

2) Added “ Last Menstrual period “ to the vital sign  sheet prepared by rooming assistants prior to the visit with a medical provider. 

3) Changed our policy from referring women to county clinics for contraception counselling and services to providing these services to patients when possible, and referring when needed for procedures we are unable to  provide.

4) Added a women’s health clinic, two afternoons per month through GMU Path program .

After the implementation of eClinicalWorks it became apparent that we had no  standardized  method  for our providers to document reproductive information. The system has multiple places and ways this information could be entered. This makes locating the information difficult to find during visits and when quality reviews are done.